“Tiering” of the Chiropractic Profession: Guess Who’s Behind this…?

Donald D. Harrison DC, PhD, MSE

Originator CBP Technique,President CBP NonProfit, Inc.

Almost as old as the profession itself is the position of a small faction within Chiropractic that adamantly argue that we would be better off if the profession were to be officially divided into different segments based upon scope, philosophy or some other principle that our profession cannot get beyond. This opinion is maintained by the extremists at each end of the spectrum. Now, after nearly 120 years, it appears that not only has this process started, but it is supported by the national groups who have been at the helm of the profession for years.

This process has taken new roots and in dangerous form in the state of New Mexico. New Mexico passed changes to its laws a year ago resulting in a “tiering” of the profession within that state. They defined, again in Statute, the designation of a “Certified advanced practice chiropractic physician”. The state law continues that this “means advanced practice chiropractor who shall have prescriptive authority for therapeutic and diagnostic purposes as authorized by statute and stated by the board.” The variety of substances that these “Advanced” chiropractors can inject into the human body, either intramuscular or intravenously, is to be determined by a panel of individuals comprised of chiropractors, medical doctors and pharmacists.

The statutory designation that these DC’s are somehow “Advanced” is presumptuous to say the least. It’s not as if this is merely some “certification” earned by a series of seminars, such as a “certified strength and conditioning specialist” or even a diplomate such as a DACBR. This is a legislated, implied superiority of certain DCs because of their right to inject “non-dangerous drugs” into patients. Whether Chiropractors wish to do this in their practice is up to them in my opinion, however the supposition that this makes them “Advanced” in any capacity over a “regular” Chiropractor is most disturbing. In no other state does this exist, for any group of Chiropractors; all Chiropractors are equal in each state. In fact I am not aware of any such “tiering” in the medical profession either. For example, while there are medical specialties and board certifications, there is no Statutory classification of MD’s into “Advanced” practitioners in any state of which I am aware. The General Practitioner MD can perform surgery should they desire.

More Than a Problem for Those in New Mexico
Right now, many of you are telling yourselves that this is New Mexico’s problem and asking… “how does it affect me?” As it turns out, the Statute in New Mexico requires a certification exam to be administered by a nationally recognized testing agency…enter the National Board of Chiropractic Examiners (NBCE). New Mexico contacted the NBCE and asked the NBCE to develop and administer a test for their state. NBCE agreed. While the NBCE explains that their purpose is merely to respond to requests for test development, in my opinion their acceptance to develop this test is a sign of support. How does an entity that has knowledge in testing Chiropractors, have the expertise to develop testing material on pharmacology, injectable delivery of substances, etc? NBCE has no expertise to develop a test on this subject matter that I’m aware of. It is my opinion that this is a farce that the NBCE has agreed to do this.
You’ll Never Guess Who Else Supports This…
To make matters worse, on October 07, 2009 the American Chiropractic Association (ACA) issued a press release titled “ACA House of Delegates Approves Policies, Elects New Leaders at Annual Meeting”. Within this press release was a short statement that the ACA House of Delegates declared that a resolution “supporting the National Board of Chiropractic Examiners’ (NBCE) plan to create certification for an expanded practice chiropractic physician…” was passed. So, the ACA has officially “supported” this process for the NBCE to develop a national certification test for these Chiropractors legislated to have an expanded scope of practice. It is logical that by declaring support for this NBCE testing process, the ACA supports “tiering” of the profession itself as well.

How Could This Affect the Profession?
At a minimum a standard is set that there are some DC’s by virtue of their practice style, are more “advanced” than other DC’s. This is contrary to most Statutes restricting DCs from implying that the manner in which they practice is in any way superior, advanced, etc. There are many scenarios that would have far greater implications for our profession. For example, would these “advanced” DC’s petition for greater insurance reimbursement to match their “expanded” practice rights? Would government run insurances be petitioned to expand the benefits allowed for these “advanced” practitioners only?

A line has been drawn in the sand. It was not drawn by a majority of the Chiropractic profession for the greater benefit of all Chiropractors…it is a line that indicates that some of our colleagues are better than the rest of us. It is a line that has been drawn not only in New Mexico, but also drawn by what are supposed to be impartial national organizations within Chiropractic…the ACA and the NBCE. This is the line that will divide our profession into segments. If you thought having two national associations resulted in underfunding and underrepresentation at the national level, wait until there are two (or in the future more) segments of the profession able to lobby for their own rights, and not the rights of all of the Chiropractic profession.
These primary care physician wannabe’s have drawn the line in the sand. The NBCE and ACA have joined with them through actions of support. Where we as a profession end with this chapter in Chiropractic history depends on the action of the average Chiropractor:

• Will you join with them, promoting assimilation into the medical model of health care as the Osteopaths did years ago?
• Or will you fight to keep our profession a drugless model of health care?

There are several ways to act…if you are a member of the ACA, demand an explanation of why the ACA supports a national certification test that divides our profession. I know MANY ACA members who do not agree with this Resolution, so let them know about your opposition to this movement. The International Chiropractors Association (ICA) is investigating this development very thoroughly before they make a determination and take action. However, be assured that the ICA will do what is best for the majority of the profession and not give in to the whims of the few who wish to divide our profession and assimilate into the medical model of health care. To join the fight, become an ICA member TODAY!
Go to www.chiropractic.org and sign up now. Your profession needs you!

Chiropractic BioPhysics, “Tiering” of the Chiropractic Profession: Guess Who’s Behind this…?

Cervical Decompression Treatment

C. Norman Shealy, MD, PhD.

President of Holos University Graduate Seminary.

Cervical Decompression Device Therapy
Considering the frequency of cervical pain, an inexpensive, yet effective, therapy seems particularly valuable. This paper reports on 36 patients with cervicogenic pain, treated with an inflatable, cervical device which provided ellipsoidal decompression of cervical vertebrae (the unit utilized in this study was the Posture Pump® with Expanding Ellipsoidal Decompression (EED™) manufactured by Posture Pro Inc, Huntington Beach, CA; www.posturepump.com).

Ellipsoidal decompression provided by the device is a process in which joints of the lordotic spinal regions (cervical and lumbar) are decompressed and simultaneously aligned in a curved or lordotic configuration. Ellipsoidal air cells expand and contract from within the lordotic spinal concavity. This unique action separates the joints at the anterior and posterior aspect of the vertebral bodies and discs in a ratio coinciding with their natural wedged spacing. Continuous expansion and contraction of the air cells can be employed to create alternating hydration and milking of the intervertebral discs. Holding the air pressure constant over a period of 15 to 20 minutes has the effect of shaping or molding the spine into a curved or ellipsoidal shape. This ellipsoidal decompression does not remove the normal curved shape from the spine as in linear traction and is therefore not harmful to the natural spinal curves.
While this device has been widely used to date with many anecdotal reports of clinical improvement, until now there have been no previous reports of MRI’s on patients using this device.
Protocol
Under an Institutional Review Board (IRB) protocol, 66 individuals were screened. All reported neck pain with or without headaches or arm pain. Thirty of the screened individuals were dropped from the study because they had either no significant cervical x-ray abnormalities or such advanced spondylosis that they were virtually fused. Of the 36 chosen, there were 26 females and 10 males, ranging in age from 18 to 65 years.

Exclusion Criteria
· Previous cervical surgery
· Spinal injury within the previous 6 months
· Individuals with pacemakers or implanted electronic devices
· Individuals with major medical illnesses
· Pregnancy

After initial history, physical, and neurologic exam, all individuals had lateral and flexion and extension lateral x-rays of the cervical spine. The 36 selected for the study all had significant postural and/or degenerative disc changes.
Patients subsequently underwent:
· Measurements of flexion and extension range of motion
· Pain intensity (0-10 scale)
· Lateral MRI of the cervical spine
· One 20 minute treatment of the ellipsoidal decompression device at 8 PSI
· Another lateral MRI immediately after the treatment
· Post Range of Motion Measurements
Results
On the initial pre/post MRI’s and single 20 minute treatment, the following changes were noted in 34 patients. (Two patients had technically inadequate MRIs because of movement).
· 1 or more decreased disc bulges 20 patients
· Disc lightening (possibly due to increased disc hydration) 16 patients
· Decreased disc bulges with spinal cord indentation 7 patients
· Increased lordotic curve 6 patients
· Stress vertebrae alignment changes 3 patients
· Changes in stair stepping of vertebrae 2 patients
· No visible MRI change 2 patients

All but 2 patients showed immediate improvement in some postural or vertebral/disc abnormality after undergoing one 20 minute treatment with the device and all patients exhibited cervical range of motion improvement. Incidentally, two patients with acute migraine improved dramatically during that 20 minute treatment.
All 36 subjects were given a Posture Pump® device to use at home and advised to use it 3 to 5 times per week. After one month, all individuals were contacted by phone for follow-up evaluation of pain intensity, frequency of usage and comments. Seven individuals also returned for follow-up MRIs.
At follow-up of 4 to 5 weeks after initial MRI, only 33 individuals could be contacted. Of those contacted, 6 had not used the Posture Pump device for various reasons—mainly “too busy.” Of the 27 who had used it, only 3 found it of no benefit. Of the 24 individuals who reported benefit:
· Average pain decreased from 5 to 2.2 out of 10—a 56% decrease in pain.
· Initial flexion increased an average of 6 degrees and extension an average of 10 degrees.

Seven of the patients had 1 month follow-up MRIs and these showed:
· 1 mm spinal widening of the canal in 4 individuals
· Disc resorption at C 5/6 as well as decreased spinal cord pressure at C5/6 in one individual.
· Improvement in lordotic curve in 6 of the 7 individuals

One individual had initial MRIs on both the lumbar and cervical spine done both before and during application. This patient showed excellent improvement in both lumbar and cervical lordosis, as well as joint expansion at both the anterior and posterior joint space during inflation. Overall, this study suggests that protruding disc material can be drawn into the disc proper as the disc expands and supports the concept of reduced inter-discal pressure with disc expansion.
As the disc expands and protruding material is drawn in, discs have a distinctly lighter color on MRI suggesting increased fluid or hydration. As kyphotic buckles are reduced, stair stepping is lessened and discs within the kyphosis expand (see Figure 1). Curve shaping and disc hydration may occur simultaneously during ellipsoidal decompression of the vertebrae.

Conclusion
Ellipsoidal decompression of cervical vertebrae utilizing the Posture Pump device provided clinical and radiographic improvement in most individuals with no adverse effects. Considering the cost, effectiveness, and ease of therapy, this treatment modality may qualify as the first line of treatment for cervicogenic pain and cervicogenic headache. (To receive a full copy of this 2006 Study and the reference citations, please contact Posture Pro, Inc. at (800) 632-5776 or email: Joanne@posturepump.com)

Figure 1. MRI’s of before and during decompression treatment.

C. Norman Shealy, MD, PhD.
President of Holos University Graduate Seminary.

cervical lordosis, Chiropractic BioPhysics, PosturePump

PostureRay® - Major UPDATES for 2010!

Joseph Ferrantelli, DC Chief of Technology CBP Seminars Private Practice New Port Richey, FL

A new year begins with PostureRay users benefitting from improved features and an added x-ray view for biomechanical assessment. Recently, as many of you already know, PostureRay was updated with CBP's short leg analysis protocols using digitization of the modified AP Ferguson view, which aids in determining the appropriate height for heel lift prescription related to an anatomical short leg or sacral deficiency related to morphology (Figure 1). The PostureRay update is the release of the APOM digitization protocol. With this new update, doctors utilizing standard x-ray or DMX can assess the APOM for ligamentous injury by digitizing and identifying possible overhang of C1 on C2 which indicates Alar and/or Accessory ligamentous damage. Lateral translation of C1 on C2 is due to an injury and subsequent sub failure of the Accessory and Alar ligaments. Documenting such findings is significant in injury cases and now with PostureRay, this type of findings is identifiable and can be demonstrated objectively (Figure 2). This powerful level of documentation is an asset to a doctor with a personal injury practice.


Figure 1. In this PostureRay Impression Report example, a comparison short leg analysis was performed after heel lift intervention was performed.


The next upgraded feature has been to the PostureRay digital viewbox. Now during a report of findings, a doctor can toggle an information pane on the x-ray, which will call up the patient’s important global measurements and their "Percentage loss/gain from normal" on their sagittal curves. This is a great aid to the doctor trying to educate a patient on the magnitude of their spinal subluxations. Prior to this, a doctor would have to refer to the findings only found in the printed report.











Figure 2. During this DMX study, the patient is lateral bending to the left during an APOM view, where abnormal 5.0mm lateral translation of C1 (GREEN) on C2 (RED) indicates damage (sub failure) of the Alar and Accessory ligaments. Normal range of lateral translation during lateral bending is <2.2mm at 72" FFD.


Additionally, for those doctors using PostureRay and the lateral full spine analysis, we have updated the system to give the doctor an option to superimpose the normal elliptical model as a continuous line up from S1 or as a sectional elliptical curve in each region, which may be more beneficial for the doctor in determining proper treatment interventions.

On the horizon, PostureRay will be incorporating the Nasium and Vertex x-ray views, along with adding other chiropractic technique biomechanical assessment protocols. For more information on PostureRay, or to view the demo videos and reports, please visit PostureCo online at www.postureco.comor email sales@postureco.com.

Chiropractic BioPhysics, PostureRay, PostureRay, x-ray digitization software, x-ray digitization software, x-ray digitization software

Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) Subluxation Based Guideline Accepted for Inclusion at the National Guideline Clearing

It is with great pleasure and humble honor that we inform you, our Chiropractic colleagues, that the PCCRP Radiographic Guideline has been accepted for inclusion at the National Guideline Clearinghouse (NGC). The NGC is a comprehensive database of evidence-based clinical practice guidelines that are accessible via the internet. On Wednesday, July 29th, we received the following letter from the National Guideline Clearing house:

“NGC- 7250: Practicing chiropractors' committee on radiology protocols (PCCRP) for biomechanical assessment of spinal subluxation in chiropractic clinical practice. The guideline has been accepted for inclusion in the National Guideline Clearinghouse.”--- Christina Latzko, MSc (Health Services Research Analyst, National Guideline Clearinghouse www.guideline.gov)

According to Dr. Deed Harrison (Chair of PCCRP), “The PCCRP guideline is the most comprehensive evaluation of the chiropractic and biomedical literature on the topic of the utilization of X-ray in a Chiropractic setting. PCCRP Contains a thorough review of the reliability, validity, clinical utility and risk-benefit ratio of numerous radiographic views, including all standard views and specialty Chiropractic views like the Nasium, Vertex, and Base Posterior.”

Also, according to Dr. Harrison, “The extent of evidence contained in the PCCRP (nearly 2000 references) robustly refutes the contention that radiography in the Chiropractic profession should be used for Red Flag conditions only (suspected tumor, infection, fracture, etc).”

Some of the key topics that are reviewed in the PCCRP Guideline include:

· Guidelines for the use of radiography in the assessment of subluxation of adults and children;

· Biomechanical definitions for 6 subluxation displacement categories with supporting evidence from the literature;

· Discussion of the risk benefit ratio associated with the use of radiography in Chiropractic practice, including the radiation hormesis vs. the linear no threshold (LNT) theory;

· Comprehensive reviews of the literature on the reliability and validity of measurement of the biomechanical component of the subluxation through line drawing mensuration, as well as the reproducibility of patient positioning for radiographic views;

· Evidence based foundation for video fluoroscopy and digital motion X-ray;

· Reviews and rates the evidence on post-treatment use of radiography, in addition to follow-up radiography to assess the effectiveness of the Chiropractic methods employed and the long-term stability of the improvements achieved;

· Legal issues of Chiropractic radiography usage as determined by the existing State Law.

The PCCRP serves as a clinical guide, specifically for Chiropractors, on the utilization of X-ray, versus adopting/supporting the guidelines written for the use of X-ray in a medical setting. It is anticipated that the PCCRP document will provide supporting evidence which may assist Chiropractors using methods that rely upon X-ray analysis to determine appropriate management and to assess the effectiveness of the care plan for a variety of patient populations.

Although, the PCCRP is officially a sub-committee of the International Chiropractors Association (ICA), the guideline committee members were a diverse group and included individuals such as Dr. Christopher Kent (one of the 5 Principle Investigators) and Dr. Dan Murphy. Of importance, the PCCRP was reviewed and endorsed by several major Chiropractic political associations and organizations:

1. The International Chiropractors Association (ICA),

2. The World Chiropractic Alliance (WCA),

3. The Federation of Straight Chiropractors Organizations(FSCO),

4. Council on Chiropractic Practice (CCP),

5. Norway Chiropractic Association,

6. Ukraine Chiropractic Association

If you would like a copy of the PCCRP Guideline you will be able to access these at http://www.ngc.gov/ in the coming weeks or you can contact the ICA at www.chiropractic.org for a printed bound copy.

Written On Behalf of the PCCRP Guideline Committee Members and the ICA,

Deed E. Harrison, DC--
Chair PCCRP Radiographic Guidelines;

Clinic Director- Ruby Mtn. Chiropractic Center, Inc.;
CBP Seminars, Inc.;
Vice President CBP NonProfit, Inc.;
Editor- American Journal of Clinical Chiropractic

Chiropractic Guidelines, PCCRP

Autism, Mercury, and High Fructose Corn Syrup

Dan Murphy, DC— Private Practice of Chiropractic; Diplomate American Board of Chiropractic Orthopedist;Faculty Life Chiropractic College West; Vice President ICA 2003-2009; ICA Chiropractor of the Year 2009

The October 2009 (1) issue of the journal Pediatrics published updated data pertaining to the incidence of Autism in US children, stating “Numerous studies have suggested that the prevalence of diagnosed Autism spectrum disorders in the US has increased dramatically in the past decades.” Studies in the early 2000’s found 1 in 166 US children to have autism, and the estimated incidence of autism in 2008 was 1 in every 151 US children. This 2009 published study estimated the incidence of autism to be 1 in every 91 US children, noting that the “prevalence is higher than previous US estimates.”

There have been constant yet controversial claims of autism incidence being linked to exposure to the neurotoxin mercury. In that regard, the following study (2) pertaining to mercury exposure as a consequence of consuming products containing High Fructose Corn Syrup is thought provoking and potentially devastating.

Mercury from chlor-alkali plants: Measured concentrations in food product sugar
KEY POINTS FROM DAN MURPHY
1) Mercury is a “potent neurological toxin.” “Mercury is a danger to unborn children whose developing brains can be damaged if they are exposed to low dose microgram exposures in the womb.”
2) Mercury is used to produce thousands of products including food ingredients such as citric acid, sodium benzoate, and high fructose corn syrup.
3) High fructose corn syrup is used in food products to enhance shelf life. It is often produced with mercury in part because mercury is a preservative.
4) This study only looked at the mercury content of high fructose corn syrup and found some samples to be significantly high in mercury content. These authors had trouble in their analysis because the companies that make high fructose corn syrup are reluctant to share their processing information and contents, claiming such information to be proprietary.
5) Even “organic” high fructose corn syrup (HFCS) uses mercury in the manufacturing process to enhance the shelf life of HFCS containing products.
6) HFCS is used as a sweetener by food manufacturers. It also stabilizes food products and enhances product shelf life.
7) This study “clearly and reliably demonstrated significant levels of mercury in 45% of the HFCS samples analyzed.”
8) “In 2004, several member states of the European Union reported finding mercury concentrations in beverages, cereals and bakery ware, and sweeteners – all of which may contain HFCS.”
9) The “FDA does not currently have a mercury surveillance program for food ingredients such as added sugars or preservatives manufactured with mercury grade chlor-alkali products.”
10) “A recent study of dietary fructose consumption among US children and adults indicate that fructose consumption by Americans represents ten percent (10%) of calories consumed in a 24-hour period.”
11) “Product labels listing HFCS as a first or second ingredient may contain detectable levels of mercury if the HFCS was manufactured with mercury grade chlor-alkali chemicals.”
12) These authors estimate that the potential average daily total mercury exposure from HFCS could be as high as 28.4 micrograms mercury. [WOW!]
13) Daily exposure of mercury from dental amalgams is significantly lower than 28.4 micrograms averaging between 0.79 to 1.91 micrograms, and “Canada and other countries do not recommend the use of mercury amalgam in pregnant women or children.”
14) “HFCS is presently ubiquitous in processed foods and therefore significantly consumed by people all over the world.”
15) “Mercury in any form – either as water-soluble inorganic salt, a lipid-soluble organic mercury compound, or as metallic mercury- is an extremely potent neurological toxin.” [Important]
16) “Organic mercury compounds such as methylmercury that are fat-soluble and readily cross the blood brain barrier are especially damaging to developing nervous tissues.”
17) Brain development is related to cumulative early life exposure to mercury. These early life exposures include the following sources:
A)) Maternal fish consumption during pregnancy [methylmercury]
B)) Thimerosal in certain vaccines (ethylmercury)
C)) Dental amalgam [inorganic mercury]
18) “In the US, the current action level of 1 micrograms methylmercury/g fish or seafood was set in 1977 during court proceedings of the United States of American v. Anderson Seafoods, Inc. The data used to determine the action level in fish came from a poisoning incident that occurred in Iraq under Saddam Hussein's regime in 1971–1972.”
19) “There has never been a blinded, placebo, controlled study published giving humans mercury or methylmercury, nor would this kind of study be ethically considerable.”
20) “Quantitative information on long-term effects of inorganic [found in dental amalgams] mercury compounds on humans does not exist.” Inorganic mercury compounds react with DNA and are clastogenic [agents that induce disruption or breakage of chromosomes].
21) “Sensitive populations such as neonates lacking the ability to efficiently excrete mercury or individuals that retain mercury in their body due to impairments in detoxification [glutathione] pathways may not be protected by any exposure limit.”
22) “The American Academy of Pediatrics has recommended that minimizing any form of mercury exposure is essential for optimal child health and nervous system development.”
23) Mercury containing chemicals may be used to make HFCS. Therefore, food products containing HFCS may also have mercury contamination.
24) “With daily per capita consumption of HFCS in the US averaging about 50 grams and daily mercury intakes from HFCS ranging up to 28 micrograms, this potential source of mercury may exceed other major sources of mercury especially in high-end consumers of beverages sweetened with HFCS.”

COMMENTS FROM DAN MURPHY
To understand more about the dangers of mercury, the book Diagnosis Mercury: Money, Politics, and Poison by Jane Hightower MD (2009) is excellent.
Based upon this study (Dufault), I believe that any product containing high fructose corn syrup should be avoided. This included most sodas, catsups, etc.
Additionally, numerous studies have linked high fructose corn syrup to both the obesity epidemic and escalating diabetes rates in the United States.

References
1) Kogan MD, Blumberg SJ, Schieve LA, et.al. Prevalence of Parent-Reported Diagnosis of Autism Spectrum Disorder Among Children in the US, 2007, Pediatrics. Volume 124, Number 4, October 2009.
2) Dufault R, LeBlanc B, Schnoll R, Cornett C, Schweitzer L, Walling D, Hightower J, Patrick L, Lukiw WJ. Mercury from chlor-alkali plants: Measured concentrations in food product sugar. Environmental Health. January 26, 2009;8:2

Dan Murphy, DC, Autism, Mercury, and High Fructose Corn Syrup

The Foot-Back Connection

Stuart Currie DC,

Director of Research, Sole Supports.
www.solesupports.com

Do foot biomechanics play a role in your clinical practice? This is a question that is answered very differently depending on your point of view. For some the answer is, “Not at all” while for others, the answer may be “Yes, with every patient”. As with many evaluation strategies, neither answer is incorrect but as is often the case the answer to this question prompts another: When should one look to the foot in a clinical situation involving the low back?
As chiropractors, we are well aware of the high prevalence and cost of low back pain. What is less obvious sometimes is the exact cause of that pain. The decision of when to look to the foot in a clinical situation can be one with philosophical consequences. It is often a question that prompts a “chicken or the egg” debate, or more specifically a “foot or back debate”. What came first, the low back problem, or the foot pathology? Is your patient limping because he has back pain, or does he have back pain because he’s limping? Many times the answer to that debate is irrelevant as a comprehensive treatment plan will encompass aspects of both areas, but often times a search to find the underlying cause of a disorder leads to a better understanding of lower extremity involvement.
A review of some relevant literature helps the discerning clinician determine if and when to look to the foot. From a structural or postural standpoint, it has been demonstrated that the severity of pes planus correlates with the prevalence of anterior keen pain and intermittent low back pain, and therefore foot screening has been recommended for patients with intermittent low back pain.1
There is also evidence that treatment of the foot with various wedges can produce measureable changes in the timing of low back and pelvic muscle activity2. This should be of particular interest to those who treat muscle imbalances. Significant postural improvements including reduction in scoliotic curves in subjects with low back pain and a measured leg length deficiency have been obtained by using wedges underfoot 3. Again, these studies lend credence to the conclusion that the foot posture affects the back.
As for how to treat a perceived abnormality, the importance of custom foot orthoses in the management of low back pain is supported by Dananberg’s work. He concluded that the treatment of chronic or acute recurrent low back pain with custom made foot orthoses is more effective than standard methods of care (at PT clinics, a physiatry center and family group practices), and that the symptoms remained improved for a longer period of time.4 Interestingly, the custom orthotic group in this study also received selective manipulation of the first MPJ, ankle and fibular head when appropriate. Furthermore, the crucial role of foot biomechanics in the management of the low back patient is illustrated by the use of foot orthoses to change abnormal lower extremity biomechanics in relation to low back pain.4-7
With the evidence in support of the foot-back connection it might seem as though treatment of the foot is a given. While this may be the case a solid knowledge of the treatment effect is required. It is not advisable to prescribe a foot orthotic in the absence of a biomechanical goal and expected objective result. The consequences for patients can be dire. For example, investigators have shown that different types of foot orthotics can affect plantar pressures differently, even causing a pressure shift that is counter to the goals of foot biomechanics8 with resultant potential consequences to the kinetic chain. This underscores the notion that any intervention that can have a positive effect, can also have a negative effect if administered improperly.
Some foot related pathologies that might prompt a practitioner to consider biomechanical etiologies include plantar fasciitis, hallux valgus deformity, morton’s neuromas, and hallux limitus. Other clinical indicators of a possible lower extremity connection include a signficiant leg length discrepancy, significant genu valgum, tibial or femoral internal rotation, and asymmetrical pronation. If you can see it, then it might be causing problems in the kinetic chain.
The obvious answer to the question posed at the beginning of this article, is that the foot should be evaluated whenever there is a suspected contribution of the foot to the clinical picture. Knowledge of the key components of foot function and their relation to the low back is crucial to a comprehensive understanding of the kinetic chain. The next step in the process is honing specific clinical evaluation skills in order to recognize the foot’s contribution. This will be discussed in a subsequent article.




Reference List
1. Kosashvili Y. Foot Ankle Int 2008 September; 29(9): 910-3.
2. Bird AR. Gait Posture 2003 October; 18(2): 81-91.
3. Bellomo RG. Gait Posture 2009;29(Supplement 1: SIAMOC 2008):e6-e7.
4. Dananberg HJ. J Am Podiatr Med Assoc 1999 March;89(3):109-17.
5. Wosk J. Arch Phys Med Rehabil 1985 March; 66(3):145-8.
6. Botte RR. J Am Podiatry Assoc 1981 May;71(5):243-53.
7. Rothbart BA. Am J Pain Manage 1995;5:84-90.
8. Hodgson B, Tis L, Cobb S. J Sport Rehab 2006;15(1):33-44.

SoleSupports, orthotics for feet, Back Pain

Vitamin D: The Versatile Nutrient

Dr. Lynn Toohey, Ph.D, Nutrition

Colorado State University in Ft. Collins, CO


It has been over a decade now since my first newsletter on vitamin D, called “Vitamin D: Discovering New Uses”. In that newsletter, I mentioned some of the various conditions for which vitamin D was gaining recognition (beyond increasing calcium/bone growth), including: Immune support (especially autoimmune disorders and cancer research), cardiovascular disease, skin disorders, nerve cell development (vitamin D is needed for NGF (nerve growth factor), peripheral neuropathy, polycystic ovarian syndrome, etc. It seems that newsletter title could easily be used again today, as vitamin D is still in the news and still constantly being regarded as the vitamin that surprises us with purported benefits, and discovered new uses.
After receiving some correspondence from a respected colleague (Dr. Deed Harrison) on the connection of vitamin D and the brain/dementia, I decided to write this article about vitamin D in the current news.

Vitamin D and the Brain
The observational evidence shows that low serum vitamin D levels are associated with increased risk for cardiovascular diseases, diabetes mellitus, depression, dental caries, osteoporosis, and periodontal disease, all of which are either considered risk factors for dementia or have preceded incidence of dementia.
One developing hypothesis about how vitamin D affects brain development is through bone morphogenetic proteins (BMP); vitamin D increases BMP, which trigger stem cells to differentiate into many different types of cells, including brain cells.1

In a study of 318 elderly participants, vitamin D insufficiency and deficiency was associated with all-cause dementia, Alzheimer disease, stroke (with and without dementia symptoms), and MRI indicators of cerebrovascular disease. The researchers proposed that the findings suggest a potential vasculoprotective role of vitamin D.2

Furthermore, a recent systematic review, while recognizing that the association between serum vitamin D concentrations and cognitive performance needs to be more clearly established, pointed out that three separate quality studies have found four significant positive associations between serum vitamin D concentrations and global cognitive functions.3

Vitamin D and Pregnancy
Scientific evidence suggests that that vitamin D deficiency may not only contribute to the risk of developing a wide range of common chronic diseases, but that the favorable biological effects of vitamin D that contribute to the improvement of human health in humans may be even more critical during pregnancy.

It appears that vitamin D insufficiency during pregnancy is potentially associated with increased risk of preeclampsia, insulin resistance and gestational diabetes mellitus. Furthermore, experimental data also anticipate that vitamin D sufficiency is critical for fetal development, and especially for fetal brain development and immunological functions. “Vitamin D deficiency during pregnancy may, therefore, not only impair maternal skeletal preservation and fetal skeletal formation but also be vital to the fetal "imprinting" that may affect chronic disease susceptibility soon after birth as well as later”.4

Vitamin D and Mood
“Recent findings from a randomized trial suggest that high doses of supplemental vitamin D may improve mild depressive symptoms”, and researchers are trying to determine a) how vitamin D may affect monoamine function and hypothalamic-pituitary-adrenal axis response to stress, b) whether vitamin D supplementation can improve mood in individuals with moderate-to-severe depression, and c) whether vitamin D sufficiency is protective against incident depression and recurrence.5

Vitamin D and P. Neuropathy
“These results suggest that active vitamin D3 could treat peripheral neuropathy by inducing NGF (nerve growth factor) production in the skin”.6
Besides nerve growth factor, vitamin D3 regulates the expression of several other growth factors that influence important pathways in the body. These factors include: insulin-like growth factor (IGF), neurotrophic factor, hepatocyte (liver cell) growth factor, and vascular endothelial growth factor (blood vessel wall lining). These growth factors are present in many areas of the body that are vitamin D-sensitive organs.

Vitamin D and MS/Cancer
Vitamin D and MS/Cancer correlations and relationships are areas of my personal research; these are topics for my next article, as they need an article dedicated to these specific conditions. Thus next time, I will discuss some of the articles I’ve written on MS7 and also the grant I’ve co-written with Immunologist Dr. Don Bellgrau, concerning the nutritional influences of vitamin D on dendritic cells and tumor antigen presentation.8
“Results from ecological, case-control and cohort studies have shown that vitamin D reduces the risk of bone fracture, falls, autoimmune diseases, type 2 diabetes, CVD and cancer”.9

Vitamin D and lupus (SLE) and fibromyalgia:
Many patients with systemic lupus erythematosus (SLE) and fibromyalgia (FM) may spend less time exposed to the sun than healthy individuals and thus might have low vitamin D levels. When studied, half the SLE and FM patients had vitamin D levels < 50 nmol/l, a level at which parathyroid (PTH) stimulation occurs. If PTH stimulation occurs, calcium will be drawn from the bone, and risk for osteoporosis will increase.

Additionally, hydroxychloroquine (HCQ) is a drug sometimes used in these patients, and data from a study “suggest that in SLE patients HCQ might inhibit the conversion to the active form of vitamin D10”.

SUMMARY & DOSAGES:
Vitamin D is both a hormone and a vitamin. Supplementation should be with the active vitamin D3; 15 minutes of sun exposure 3 X week is adequate for most people, although logistics and concerns about skin cancer make supplementation a viable option. Recommended doses for vitamin D have been changing as the benefits of supplementation have become evident; however, it is prudent to treat this fat-soluble vitamin with respect.

Although when I received my PhD the upper limit was set at 2000-2400 IUs per day, dosages these days sometimes run into thousands more IUs per day. The caution would be that it is wise to monitor with lab tests (serum calcium or vitamin D), especially for liability purposes, since the RDIs and upper limits have not technically been changed yet. Blood calcium is tightly regulated, and increases are a major concern. Vitamin D supplementation is contraindicated in sarcoidosis, and although uncommon, can cause hypercalcemia.

References
1. Chen HL, Panchision DL. Stem Cells 2007; Vol. 25, no. 1: 63–68.
2. Buell JS, Dawson-Hughes B, et al. Neurology. 2009 Nov 25.
3. Annweiler C, Allali G, et al. Eur J Neurol. 2009 Oct;16(10):1083-9.
4. Lapillonne A. Med Hypotheses. 2010 Jan;74(1):71-5.
5. Bertone-Johnson ER. Nutr Rev. 2009 Aug;67(8):481-92.
6. Fukuoka M, et al. Skin Pharmacol Appl Skin Physiol 2001 Jul-Aug;14(4):226-33.
7. Toohey, L. J Brit Soc Allergy Env & Nutr Med 2005.
8. Bellgrau, D & Toohey, L. ACIR grant, 2009.
9. Wang S. Nutr Res Rev. 2009 Dec;22(2):188-203.
10. Huisman AM et al. J Rheumatol 2001 Nov;28(11):2535

Nutriwest, Vitamin D

3 CHALLENGES MOST MANAGEMENT GROUPS MAKE RECOMMENDING SPINAL REHAB

Fred DiDomenico, DC

Practice Coach and Mentor

There are many chiropractic management groups available and all have great tools for helping a doctor teach traditional chiropractic. The principles I will discuss in this article originate from the feedback of many doctors all over the country wanting to use or using spinal rehab techniques that are presently involved with a management group or have invested in a management group in the past.

First of all, there is a significant difference between management groups that recommend a spinal rehab technique vs. specializing in spinal rehab technique. Many groups will suggest you study a corrective technique, yet accept you using any technique you desire. These groups are on the right track because it is truth throughout the profession that patients committing to spinal corrective programs are “buying” a more valuable service, spinal CORRECTION. This is the vehicle management groups use to teach doctors how to inspire pre-pays, increase your retention, establish your uniqueness, teach patients why they should pay you past their insurance coverage, refer and more.
You are RECOMMENDED to study spinal rehab techniques because the ROF you will be trained to deliver to see these benefits in your practice will be geared toward spinal correction. Since they don’t TRULY specialize in spinal rehab, 3 problems begin to occur from this moment forward.

#1. The doctor and staff may not have the confidence to see the full benefits of true spinal correction:
If you and your team are not achieving the spinal correction you are attempting to teach the patient at the ROF, 2 problems occur.
1. You will not have confidence on the post x-ray. You may relay to the patient your reasons why the patient didn’t see the change they wanted or just avoid the post x-ray completely.
2. You will not see the true health benefits of spinal correction.
Spinal correction will heal organ problems and reverse the aging process of the body. Traditional chiropractic is truly miraculous. Spinal correction can achieve health restorative benefits and function far beyond traditional chiropractic care including disc rehydration. When you correct spinal structure with predictable disc rehydration, you will see health benefits in your patients that will be unprecedented compared to your current practice. Anti-Aging is driving the gross national product of this country today. Spinal correction can minimally slow and in some, reverse the aging process of the body.

#2. Selling Arthritis:
Many management groups suggest you create value through the progressive degenerative process of arthritis. In a ROF, you are instructed to use the Phases of Degeneration Chart and show how their condition will eventually progress. Again, there are 2 challenges using this educational tool.
1. Many people in the general public expect to get arthritis as they get older. It is sometimes difficult to change the perspective of some patients that have already accepted this destiny regardless of their health benefit, especially if they did not make their health a financial priority.
2. There is progression with teaching arthritis, but not urgency. Progression means it will get worse. Urgency is why they will pay you TODAY! Most management groups are great at teaching progression, few are great teaching urgency. These same groups teaching arthritis DON’T teach posture and organ dysfunction. Patients will pay you today when you can help them correct posture, improve their organ function and overall health as well as have the ability to live a healthy life at any age with a healthy spinal structure. This truth is well supported in research.

#3. Spinal Rehab has a MUCH greater value:
Most techniques recommending spinal rehab techniques teach traditional chiropractic, which does not create the same value for your spinal rehab services. Spinal rehab is like running a therapy clinic. The actual technique required to create spinal correction is very far from traditional adjustment practices. These techniques require more service, more staff, and more equipment. When you teach the full benefits of spinal correction your clinical results AND income skyrocket IF you have a coaching system that is specific for this model. The communication system is much different than traditional chiropractic. Most management groups recommend spinal rehab, yet create the value for traditional chiropractic care. In reality, the 2 don’t match value. These specific techniques require specific coaching to receive the full benefits in these practices.
If you choose to use the most successful and purpose based chiropractic systems in the profession, spinal correction, use a coaching system that is specific for this unique type of practice to ensure your success.

Chiropractic BioPhysics, Elite Coaching

CHIROPRACTIC BUSINESS—and how to lower your overhead!

Eric Huntington, DC

Co-Owner Developer of the Chiropractic Business Academy

CHIROPRACTIC BUSINESS
There are two distinct aspects of owning a chiropractic practice. Each is a separate “hat”, which, when worn skillfully, leads to an optimal outcome—but when not known, or applied improperly, can lead to frustration and unhappiness.
1) The Chiropractic Technique Hat-- meaning the compilation of the knowledge and skills necessary to delivering chiropractic service.
2) The Chiropractic Business Hat—meaning the compilation of the knowledge and skills necessary to build and manage every aspect of chiropractic practice(s).
The Chiropractic Business Hat has been missing from the chiropractic profession for quite some time. Despite many successful clinics and management firms over the decades, the subject of Chiropractic Business has barely been touched upon in earnest until very recently.
This is so obvious, that it is almost hard to spot. Want proof? Look at the condition of most chiropractic clinics. Maybe take a look at your clinic.
Now, I’ll be the first to tell you that if you are happy with your clinic and it provides help to those you serve, then there is probably nothing wrong with it unless you think so.
But if you think it could be better, ask yourself these questions.
1) Can I spend two solid weeks on vacation or handling other aspects of my life without disrupting my income?
2) Does my practice provide the full scope of service that I truly believe each patient should get-- or do I shortcut for lack of time or finance?
3) Do I have adequate cash reserves to make it through at least 3 months with no income? Does my income meet my needs/expectations?
4) Do I have certainty that I have adequate knowledge of chiropractic business to allow me to adapt to changes in the economy/ health care?
5) Can I count on my practice income if I get injured or my body just can’t deliver adjustments anymore?
6) Am I happy with the impact I am making through chiropractic, or do I wish I could create a bigger effect?
If these questions make you feel uneasy or you just would like to know how to solve these problems, then you would benefit from learning and applying the full Chiropractic Business Hat. Through the Chiropractic Business Academy, I teach doctors the full Chiropractic Business Hat. Following our training and apprenticeships, Chiropractic Business Academy clients have certainty on how to handle 1-5 above-- and most of them can say that they are well on their way to achieving #6!

So, “What is the Subject of Chiropractic Business?”
It is the science of understanding, building and running every aspect of a chiropractic practice(s) organized in such a manner as to allow the Chiropractic Executive ease of use in his trade—whether he runs one clinic or a hundred.
This subject would have to include hiring, training and motivating staff, organization down to the last detail, selling, retention, collecting and managing money, quality control, handlings for ineffective staff and various statistical trends, promotion, marketing, handling the area outside your clinic to make it safe for your chiropractic expansion, legal strategies, contract negotiations, property acquisition and maintenance, -- just to name a few.
Just as important, these various aspects of chiropractic business would have to each be organized in such a way as to allow for efficient learning and application to chiropractic practice.
This means the data would have to be standard in its application—meaning that when applied properly, it works all the time. If this idea of a subject being properly applied and always working sounds strange to you, it is only because there are so many poorly organized, non-standard bodies of data in the world.
However, when standard chiropractic business is applied properly, expansion always occurs. In fact, we are so sure of this fact, that The Chiropractic Business Academy provides a guarantee to each new client that he/she will double the investment in our program within the first 12 months. Even in a down trending economy we guarantee you will make more!
To learn more about the Chiropractic Business Hat and To learn more about how The Chiropractic Business Academy can guarantee your success call our office and speak to one of our consultants. Having trouble with a specific problem, ask for a “Free Practice Trouble Shoot”. CALL NOW: 888-989-0855. Or visit us on the web at, www.Chirobizacademy.com
Remember the practice that you dreamed of owning in the beginning? Don’t give up on it. I look forward to meeting with you!

BONUS ARTICLE
“How To Lower My Overhead”. At one time or another, and maybe quite often for some, this question of “What should my overhead be?” has probably crossed your mind. There are many ways to decrease your overhead including… (This article is continued at www.chirobizacademy.com )

Chiropractic Business Academy

Contemporary Chiropractic Research Is Not Simply for Pain…

Len Siskin, DC Promote Chiropractic, Co-Chair ICA Best Practices

As most of us realize, chiropractic is a special and unique profession where the information we have about what we do has evolved over the years. Ironically, when taking a critical look at the practical application of chiropractic adjustments performed in most chiropractic offices, the foundation of making an adjustment to the spine largely stays the same. Even in the clinics where they choose to employ modalities of a more medical flavor like decompression, cold laser, or where the chiropractor might integrate rehabilitation or a physical therapist, the general chiropractic part of the treatment largely remains… chiropractic. When asked, most Chiropractors hold a value for correcting the chiropractic subluxation as well rather than embracing a pain management model despite what they choose to tell their patients.

Because the chiropractic part of chiropractic practice seems similar to the way it has been practiced for many years by many Chiropractors, it is interesting to see that chiropractic research is also still not dedicated solely to pain relief of low back and neck. In fact, the most recent meeting of volunteers to read and rate research for the ICA Best Practices Guidelines document held in November, 2009 in NJ, found that the following conditions in chiropractic research papers were shown to receive help from chiropractic intervention (in alphabetical order):

Acetabular Labrum Injury, Adhesive Capsulitis, Bronchopulmonary Dysplasia, Bulbar Palsy, Cerebral Palsy, Costochondritis, Dysmenorrhea, Foraminal Stenosis, Knee Arthritis, Lateral Epicondylalgia, Low Back Pain, Neck Pain, Paroxysmal Supraventricular Tachycardia, Subluxation, Tibialis Posterior Strain, and Viral Torticollis.

All of these named health conditions were in chiropractic research papers from 2007-2009 and do not represent all published chiropractic papers as we have not exhausted our data update through 2009 yet. This will be done in the first half of 2010.

The highest treatment amount in this set of papers was 76 treatment visits with the average number of treatment visits being TWENTY! Overall, only 4% of the studies we reviewed failed to show positive treatment outcomes. It was interesting that of papers failing to show effectiveness of treatment; all but one was performed by a non-Chiropractor (Generally an MD or PT). In the one rated paper failing to show a positive treatment outcome by a Chiropractor, the measurement being considered was for normal mouth opening. As is typical for chiropractic research, 76% of papers were observational studies such as case studies (Level III and IV evidence), and the remaining studies were clinical control trials (Level I and II evidence). Opinion papers (Level V Evidence) were not included nor were academic papers or research papers not working with human subjects.

On a whim I typed, “Research in Chiropractic”, into a Google search. The outcome of this is actually pretty impressive. As a chiropractor in clinical practice, I am all too familiar with common misperceptions held by the general public about our profession. Just the other day a newspaper reporter, who called me to ask for an interview, asked if chiropractic was a two year degree or if I had to go to formal school for my license. The same woman was further in shock when a patient of mine told her I adjust my three year old son.

Searching Google resulted in a more cosmopolitan representation of our profession. In determination to find something bad or negative about chiropractic in this list to complain about, I was delighted to find it took until hit number 126 to see anything that tightened my stomach as a Chiropractor. In fact, hit 126 was banter between the president of the ACA and the President and CEO of the Public Broadcasting Service from June 2002 on a broadcast of, “Scientific American Frontiers”. The two people involved were arguing the possibility of performing scientific research in chiropractic. As far as bad PR for our profession goes, I thought this was not so terrible. I have found some of the best public relations material in our profession is in our published research. The information thankfully speaks positively about chiropractic pretty much any way you look at it.

Along these lines, the ICA Best Practices Guidelines Database currently holds over 1400 original research studies of which only 17 chiropractic papers (about 1%) failed to show positive improvement in patients and none indicated significant, long-term risk or damage from chiropractic treatment. The ones not showing improvement simply did not show improvement. On the other hand, 99% of the papers published show chiropractic has helped a growing list of about 304 named health disorders/conditions using chiropractic treatment.

Critics might believe: “Aren’t those chiropractic papers published only in trade journals?” However, the research papers reviewed at the November 2009 meeting were from indexed publications; let’s look… BMC Musculoskeletal Disorders, Chiropractic and Osteopathy, Chiropractic Journal Of Australia, Clinical Chiropractic, Complementary Therapies in Medicine, Dynamic Chiropractic, European Spine Journal, Journal Canadian Chiropractic Association, Journal of Alternative And Complimentary Medicine, Journal of Chiropractic Education, Journal Of Chiropractic Medicine, Journal Of Clinical Chiropractic Pediatrics, Journal Of Manipulative And Physiologic Therapeutics, Journal Of Manual And Manipulative Therapy, Journal of Orthopedic and Sports Physical Therapy, Journal of The American Chiropractic Association, Journal of Vertebral Subluxation Research, Physical Therapy, & Spine.
http://www.icabestpractices.org/

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines